BBC Care Service Limited received an overall rating of Requires Improvement at its first inspection, with Safe and Well-Led domains both requiring improvement due to missed/late visits, absence of incident trend analysis, and lack of data analysis from audits and feedback. Effective, Caring and Responsive domains were rated Good, reflecting well-trained staff, personalised care plans, and respectful, person-centred practice.
Concerns (6)
moderateMissed or late visits: “Last Thursday they completely missed a visit and did not turn up at all”
moderateIncident learning: “There was no formal system to investigate and analyse incidents to look for trends and help prevent reoccurrence.”
moderateGovernance: “There was little analysis of information obtained from audits and monitoring that would allow the registered manager to look for patterns and trend.”
moderateConsent / capacity: “Some documents had been signed by relatives who did not have authority to do so.”
minorCommunication with families: “We have not been given any information about the service, no booklet or phone number, just the number of a carer but not who to phone in an emergency.”
minorComplaints handling: “I tried to make a complaint, but the call did not connect to the land line, and it didn't connect to the mobile either.”
Strengths
· Medicines were managed safely with accurate, consistently maintained records and staff trained in administering medicines safely.
· Staff were recruited safely with appropriate DBS checks and sufficient staffing levels maintained.
· Risk assessments were in place and regularly reviewed with detailed guidance for staff.
· Care plans were personalised, person-centred and regularly reviewed.
· Staff were well trained, completed induction linked to the Care Certificate, and received ongoing relevant training.
Quality-Statement breakdown (23)
safe: Staffing and recruitmentRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End-of-life care and supportGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Continuous learning and improving care; Working in partnership with othersGood
well-led: How the provider understands and acts on the duty of candourGood